|
CPLX RPR FACE 2.6-7.5 CM(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
761P0156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.79 |
| Max. Negotiated Rate |
$716.35 |
| Rate for Payer: Aetna Commercial |
$658.61
|
| Rate for Payer: Ambetter Exchange |
$282.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$152.79
|
| Rate for Payer: Anthem Medicaid |
$256.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$282.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$282.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$339.49
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$716.35
|
| Rate for Payer: Healthspan PPO |
$636.61
|
| Rate for Payer: Humana Medicaid |
$256.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$588.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$282.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$282.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$261.94
|
| Rate for Payer: Molina Healthcare Passport |
$256.80
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$367.78
|
| Rate for Payer: UHCCP Medicaid |
$160.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$259.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$282.91
|
|
|
CPLX RPR FACE 2.6-7.5 CM(T
|
Facility
|
IP
|
$1,795.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
761T0156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$538.50 |
| Max. Negotiated Rate |
$1,723.20 |
| Rate for Payer: Aetna Commercial |
$1,382.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,400.10
|
| Rate for Payer: Cash Price |
$897.50
|
| Rate for Payer: Cigna Commercial |
$1,489.85
|
| Rate for Payer: First Health Commercial |
$1,705.25
|
| Rate for Payer: Humana Commercial |
$1,525.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,324.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,579.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,346.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,561.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,238.55
|
| Rate for Payer: PHCS Commercial |
$1,723.20
|
| Rate for Payer: United Healthcare All Payer |
$1,579.60
|
|
|
CPLX RPR FACE 2.6-7.5 CM(T
|
Facility
|
OP
|
$1,795.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
761T0156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$1,723.20 |
| Rate for Payer: Aetna Commercial |
$1,382.15
|
| Rate for Payer: Anthem Medicaid |
$617.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,400.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$897.50
|
| Rate for Payer: Cash Price |
$897.50
|
| Rate for Payer: Cigna Commercial |
$1,489.85
|
| Rate for Payer: First Health Commercial |
$1,705.25
|
| Rate for Payer: Humana Commercial |
$1,525.75
|
| Rate for Payer: Humana KY Medicaid |
$617.30
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$623.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,324.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,579.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,346.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,561.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,238.55
|
| Rate for Payer: PHCS Commercial |
$1,723.20
|
| Rate for Payer: United Healthcare All Payer |
$1,579.60
|
|
|
CPLX RPR SC - EXT 1.1-2.5
|
Facility
|
OP
|
$1,868.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
76100152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$1,793.28 |
| Rate for Payer: Aetna Commercial |
$1,438.36
|
| Rate for Payer: Anthem Medicaid |
$642.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,457.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$934.00
|
| Rate for Payer: Cash Price |
$934.00
|
| Rate for Payer: Cigna Commercial |
$1,550.44
|
| Rate for Payer: First Health Commercial |
$1,774.60
|
| Rate for Payer: Humana Commercial |
$1,587.80
|
| Rate for Payer: Humana KY Medicaid |
$642.41
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$648.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,531.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,378.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$655.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,643.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,401.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,494.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,625.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,288.92
|
| Rate for Payer: PHCS Commercial |
$1,793.28
|
| Rate for Payer: United Healthcare All Payer |
$1,643.84
|
|
|
CPLX RPR SC - EXT 1.1-2.5
|
Professional
|
Both
|
$1,868.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
76100152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.01 |
| Max. Negotiated Rate |
$1,120.80 |
| Rate for Payer: Aetna Commercial |
$349.33
|
| Rate for Payer: Ambetter Exchange |
$215.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$118.01
|
| Rate for Payer: Anthem Medicaid |
$135.71
|
| Rate for Payer: Buckeye Individual/Medicaid |
$215.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$215.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$258.11
|
| Rate for Payer: Cash Price |
$934.00
|
| Rate for Payer: Cash Price |
$934.00
|
| Rate for Payer: Cigna Commercial |
$426.18
|
| Rate for Payer: Healthspan PPO |
$361.48
|
| Rate for Payer: Humana Medicaid |
$135.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$306.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$215.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$215.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$138.42
|
| Rate for Payer: Molina Healthcare Passport |
$135.71
|
| Rate for Payer: Multiplan PHCS |
$1,120.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$279.62
|
| Rate for Payer: UHCCP Medicaid |
$123.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$137.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$215.09
|
|
|
CPLX RPR SC - EXT 1.1-2.5
|
Facility
|
IP
|
$1,868.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
76100152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.40 |
| Max. Negotiated Rate |
$1,793.28 |
| Rate for Payer: Aetna Commercial |
$1,438.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,457.04
|
| Rate for Payer: Cash Price |
$934.00
|
| Rate for Payer: Cigna Commercial |
$1,550.44
|
| Rate for Payer: First Health Commercial |
$1,774.60
|
| Rate for Payer: Humana Commercial |
$1,587.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,531.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,378.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$560.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,643.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,401.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,494.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,625.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,288.92
|
| Rate for Payer: PHCS Commercial |
$1,793.28
|
| Rate for Payer: United Healthcare All Payer |
$1,643.84
|
|
|
CPLX RPR SC - EXT 1.1-2.5(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
761P0152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.01 |
| Max. Negotiated Rate |
$426.18 |
| Rate for Payer: Aetna Commercial |
$349.33
|
| Rate for Payer: Ambetter Exchange |
$215.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$118.01
|
| Rate for Payer: Anthem Medicaid |
$135.71
|
| Rate for Payer: Buckeye Individual/Medicaid |
$215.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$215.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$258.11
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$426.18
|
| Rate for Payer: Healthspan PPO |
$361.48
|
| Rate for Payer: Humana Medicaid |
$135.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$306.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$215.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$215.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$138.42
|
| Rate for Payer: Molina Healthcare Passport |
$135.71
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$279.62
|
| Rate for Payer: UHCCP Medicaid |
$123.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$137.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$215.09
|
|
|
CPLX RPR SC - EXT 1.1-2.5(T
|
Facility
|
OP
|
$1,443.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
761T0152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$496.25 |
| Max. Negotiated Rate |
$1,385.28 |
| Rate for Payer: Aetna Commercial |
$1,111.11
|
| Rate for Payer: Anthem Medicaid |
$496.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,125.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$721.50
|
| Rate for Payer: Cash Price |
$721.50
|
| Rate for Payer: Cigna Commercial |
$1,197.69
|
| Rate for Payer: First Health Commercial |
$1,370.85
|
| Rate for Payer: Humana Commercial |
$1,226.55
|
| Rate for Payer: Humana KY Medicaid |
$496.25
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$501.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,183.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,064.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$506.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,269.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,082.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,154.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,255.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$995.67
|
| Rate for Payer: PHCS Commercial |
$1,385.28
|
| Rate for Payer: United Healthcare All Payer |
$1,269.84
|
|
|
CPLX RPR SC - EXT 1.1-2.5(T
|
Facility
|
IP
|
$1,443.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
761T0152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.90 |
| Max. Negotiated Rate |
$1,385.28 |
| Rate for Payer: Aetna Commercial |
$1,111.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,125.54
|
| Rate for Payer: Cash Price |
$721.50
|
| Rate for Payer: Cigna Commercial |
$1,197.69
|
| Rate for Payer: First Health Commercial |
$1,370.85
|
| Rate for Payer: Humana Commercial |
$1,226.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,183.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,064.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$432.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,269.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,082.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,154.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,255.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$995.67
|
| Rate for Payer: PHCS Commercial |
$1,385.28
|
| Rate for Payer: United Healthcare All Payer |
$1,269.84
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
OP
|
$1,403.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
76100153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$482.49 |
| Max. Negotiated Rate |
$1,346.88 |
| Rate for Payer: Aetna Commercial |
$1,080.31
|
| Rate for Payer: Anthem Medicaid |
$482.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,094.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$701.50
|
| Rate for Payer: Cash Price |
$701.50
|
| Rate for Payer: Cigna Commercial |
$1,164.49
|
| Rate for Payer: First Health Commercial |
$1,332.85
|
| Rate for Payer: Humana Commercial |
$1,192.55
|
| Rate for Payer: Humana KY Medicaid |
$482.49
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$487.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,150.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,035.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$492.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,234.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,052.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,122.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$968.07
|
| Rate for Payer: PHCS Commercial |
$1,346.88
|
| Rate for Payer: United Healthcare All Payer |
$1,234.64
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Professional
|
Both
|
$1,403.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
76100153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.78 |
| Max. Negotiated Rate |
$841.80 |
| Rate for Payer: Aetna Commercial |
$457.37
|
| Rate for Payer: Ambetter Exchange |
$241.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$129.78
|
| Rate for Payer: Anthem Medicaid |
$204.69
|
| Rate for Payer: Buckeye Individual/Medicaid |
$241.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$241.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$290.18
|
| Rate for Payer: Cash Price |
$701.50
|
| Rate for Payer: Cash Price |
$701.50
|
| Rate for Payer: Cigna Commercial |
$538.97
|
| Rate for Payer: Healthspan PPO |
$483.39
|
| Rate for Payer: Humana Medicaid |
$204.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$241.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$241.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$208.78
|
| Rate for Payer: Molina Healthcare Passport |
$204.69
|
| Rate for Payer: Multiplan PHCS |
$841.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$314.37
|
| Rate for Payer: UHCCP Medicaid |
$136.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$206.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$241.82
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
OP
|
$853.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
45000070
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$293.35 |
| Max. Negotiated Rate |
$818.88 |
| Rate for Payer: Aetna Commercial |
$656.81
|
| Rate for Payer: Anthem Medicaid |
$293.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$665.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$426.50
|
| Rate for Payer: Cash Price |
$426.50
|
| Rate for Payer: Cigna Commercial |
$707.99
|
| Rate for Payer: First Health Commercial |
$810.35
|
| Rate for Payer: Humana Commercial |
$725.05
|
| Rate for Payer: Humana KY Medicaid |
$293.35
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$296.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$699.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$629.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$299.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$750.64
|
| Rate for Payer: Ohio Health Group HMO |
$639.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$682.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$742.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$588.57
|
| Rate for Payer: PHCS Commercial |
$818.88
|
| Rate for Payer: United Healthcare All Payer |
$750.64
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
IP
|
$853.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
45000070
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$255.90 |
| Max. Negotiated Rate |
$818.88 |
| Rate for Payer: Aetna Commercial |
$656.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$665.34
|
| Rate for Payer: Cash Price |
$426.50
|
| Rate for Payer: Cigna Commercial |
$707.99
|
| Rate for Payer: First Health Commercial |
$810.35
|
| Rate for Payer: Humana Commercial |
$725.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$699.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$629.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$750.64
|
| Rate for Payer: Ohio Health Group HMO |
$639.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$682.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$742.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$588.57
|
| Rate for Payer: PHCS Commercial |
$818.88
|
| Rate for Payer: United Healthcare All Payer |
$750.64
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
IP
|
$1,403.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
76100153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.90 |
| Max. Negotiated Rate |
$1,346.88 |
| Rate for Payer: Aetna Commercial |
$1,080.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,094.34
|
| Rate for Payer: Cash Price |
$701.50
|
| Rate for Payer: Cigna Commercial |
$1,164.49
|
| Rate for Payer: First Health Commercial |
$1,332.85
|
| Rate for Payer: Humana Commercial |
$1,192.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,150.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,035.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,234.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,052.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,122.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$968.07
|
| Rate for Payer: PHCS Commercial |
$1,346.88
|
| Rate for Payer: United Healthcare All Payer |
$1,234.64
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
761P0153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.78 |
| Max. Negotiated Rate |
$538.97 |
| Rate for Payer: Aetna Commercial |
$457.37
|
| Rate for Payer: Ambetter Exchange |
$241.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$129.78
|
| Rate for Payer: Anthem Medicaid |
$204.69
|
| Rate for Payer: Buckeye Individual/Medicaid |
$241.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$241.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$290.18
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$538.97
|
| Rate for Payer: Healthspan PPO |
$483.39
|
| Rate for Payer: Humana Medicaid |
$204.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$241.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$241.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$208.78
|
| Rate for Payer: Molina Healthcare Passport |
$204.69
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$314.37
|
| Rate for Payer: UHCCP Medicaid |
$136.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$206.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$241.82
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM(T
|
Facility
|
OP
|
$853.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
761T0153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$293.35 |
| Max. Negotiated Rate |
$818.88 |
| Rate for Payer: Aetna Commercial |
$656.81
|
| Rate for Payer: Anthem Medicaid |
$293.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$665.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$426.50
|
| Rate for Payer: Cash Price |
$426.50
|
| Rate for Payer: Cigna Commercial |
$707.99
|
| Rate for Payer: First Health Commercial |
$810.35
|
| Rate for Payer: Humana Commercial |
$725.05
|
| Rate for Payer: Humana KY Medicaid |
$293.35
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$296.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$699.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$629.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$299.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$750.64
|
| Rate for Payer: Ohio Health Group HMO |
$639.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$682.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$742.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$588.57
|
| Rate for Payer: PHCS Commercial |
$818.88
|
| Rate for Payer: United Healthcare All Payer |
$750.64
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM(T
|
Facility
|
IP
|
$853.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
761T0153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.90 |
| Max. Negotiated Rate |
$818.88 |
| Rate for Payer: Aetna Commercial |
$656.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$665.34
|
| Rate for Payer: Cash Price |
$426.50
|
| Rate for Payer: Cigna Commercial |
$707.99
|
| Rate for Payer: First Health Commercial |
$810.35
|
| Rate for Payer: Humana Commercial |
$725.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$699.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$629.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$750.64
|
| Rate for Payer: Ohio Health Group HMO |
$639.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$682.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$742.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$588.57
|
| Rate for Payer: PHCS Commercial |
$818.88
|
| Rate for Payer: United Healthcare All Payer |
$750.64
|
|
|
CPO MEDICARE/HOSP 15-29 MIN(P
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
510P0094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$97.67 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.67
|
| Rate for Payer: Healthspan PPO |
$77.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.22
|
| Rate for Payer: Multiplan PHCS |
$70.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.60
|
| Rate for Payer: UHCCP Medicaid |
$41.30
|
|
|
CPO MEDICARE/HOSPICE 15-29 MIN
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
51000094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
CPO MEDICARE/HOSPICE 15-29 MIN
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
51000094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$97.67 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.67
|
| Rate for Payer: Healthspan PPO |
$77.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.22
|
| Rate for Payer: Multiplan PHCS |
$70.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.60
|
| Rate for Payer: UHCCP Medicaid |
$41.30
|
|
|
CPO MEDICARE/HOSPICE 15-29 MIN
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
51000094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.40 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.42
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
[C]PROMETH WITH CODEINE S 10ML
|
Facility
|
IP
|
$60.57
|
|
|
Service Code
|
NDC 27808006502
|
| Hospital Charge Code |
25000116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$58.15 |
| Rate for Payer: Aetna Commercial |
$46.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.24
|
| Rate for Payer: Cash Price |
$30.28
|
| Rate for Payer: Cigna Commercial |
$50.27
|
| Rate for Payer: First Health Commercial |
$57.54
|
| Rate for Payer: Humana Commercial |
$51.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.30
|
| Rate for Payer: Ohio Health Group HMO |
$45.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.79
|
| Rate for Payer: PHCS Commercial |
$58.15
|
| Rate for Payer: United Healthcare All Payer |
$53.30
|
|
|
[C]PROMETH WITH CODEINE S 10ML
|
Facility
|
OP
|
$60.57
|
|
|
Service Code
|
NDC 27808006502
|
| Hospital Charge Code |
25000116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.17 |
| Max. Negotiated Rate |
$58.15 |
| Rate for Payer: Aetna Commercial |
$46.64
|
| Rate for Payer: Anthem Medicaid |
$20.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.24
|
| Rate for Payer: Cash Price |
$30.28
|
| Rate for Payer: Cigna Commercial |
$50.27
|
| Rate for Payer: First Health Commercial |
$57.54
|
| Rate for Payer: Humana Commercial |
$51.48
|
| Rate for Payer: Humana KY Medicaid |
$20.83
|
| Rate for Payer: Kentucky WC Medicaid |
$21.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.30
|
| Rate for Payer: Ohio Health Group HMO |
$45.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.79
|
| Rate for Payer: PHCS Commercial |
$58.15
|
| Rate for Payer: United Healthcare All Payer |
$53.30
|
|
|
CPS AIM SL CATH 26*59CM
|
Facility
|
OP
|
$2,022.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$606.60 |
| Max. Negotiated Rate |
$1,941.12 |
| Rate for Payer: Aetna Commercial |
$1,556.94
|
| Rate for Payer: Anthem Medicaid |
$695.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,577.16
|
| Rate for Payer: Cash Price |
$1,011.00
|
| Rate for Payer: Cigna Commercial |
$1,678.26
|
| Rate for Payer: First Health Commercial |
$1,920.90
|
| Rate for Payer: Humana Commercial |
$1,718.70
|
| Rate for Payer: Humana KY Medicaid |
$695.37
|
| Rate for Payer: Kentucky WC Medicaid |
$702.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,658.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,492.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$606.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$709.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,779.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,516.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,617.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,759.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,395.18
|
| Rate for Payer: PHCS Commercial |
$1,941.12
|
| Rate for Payer: United Healthcare All Payer |
$1,779.36
|
|
|
CPS AIM SL CATH 26*59CM
|
Facility
|
IP
|
$2,022.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$606.60 |
| Max. Negotiated Rate |
$1,941.12 |
| Rate for Payer: Aetna Commercial |
$1,556.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,577.16
|
| Rate for Payer: Cash Price |
$1,011.00
|
| Rate for Payer: Cigna Commercial |
$1,678.26
|
| Rate for Payer: First Health Commercial |
$1,920.90
|
| Rate for Payer: Humana Commercial |
$1,718.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,658.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,492.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$606.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,779.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,516.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,617.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,759.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,395.18
|
| Rate for Payer: PHCS Commercial |
$1,941.12
|
| Rate for Payer: United Healthcare All Payer |
$1,779.36
|
|
